Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you expect a different response rate to neradomilast depending on the ILD phenotype?
The best data to address this query come from the FIBRONEER-ILD trial, where approximately 70% of patients at enrollment had a UIP or UIP-like pattern on CT. The response to nerandomilast therapy was significant in both groups (with UIP or another pattern). In fact, the numerical results were greate...
What is the recommended fungal workup in an immunocompromised patient after 5 days of persistent fever?
For any patient with fevers, I focus significantly on any symptoms that a patient might have, like headache, diarrhea, and sinus symptoms, and work up a differential diagnosis based on possible pathogens in this area. If I am not finding anything, I would obtain a CT chest/abd/pelvis, as both invasi...
Would you start treatment for MAC in a patient with nodular bronchiectatic disease who has demonstrated radiographic progression but remains asymptomatic and smear-negative?
My default answer would be yes; this is a sign of progressive disease that will get worse without treatment. Having said that many things could be considered while making the decision, including patient preferences. First is there another cause? Does the patient have an exacerbation of bronchiectasi...
In a patient with medically refractory, lung-limited stage IV NSCLC and progressive respiratory failure, when would you consider referral for lung transplantation?
Never. Cancer will reduce life expectancy per se, especially if it is stage IV. Malignancy is usually a contraindication to any transplant.
When, if ever, would you consider methotrexate over prednisone for first line therapy in patients with pulmonary sarcoidosis?
The PREDMETH trial supports the use of methotrexate for initial therapy for sarcoidosis. Future studies may identify subgroups that may benefit from the concurrent use of prednisone initially; it is unclear how soon methotrexate may provide symptomatic relief compared to the ability of an appropriat...
In patients with ILD who are started on nerandomilast on top of background nintedanib, what monitoring is most important early in therapy?
While it may seem initially that combining antifibrotics is a bad idea due to side effect profiles, it has, in fact, been done with some success. The INJOURNEY trial combined nintedanib AND perfenidone in patients with IPF, and during the study period (12 weeks), those on combined therapy lost only ...
Would you stop Dupixent in an asthma patient who has good asthma control and notes improvement in loss of smell, but shows notable eosinophil elevation after 4-5 doses of the medication?
Transient eosinophilia has been reported in patients treated with Dupixent, likely related to downregulation of eotaxin and adhesion molecules resulting in impaired eosinophil migration into the tissues (Castro et al., PMID 29782217, Olaguibel et al., PMID 35522053). This phenomenon is typically see...
How are you using liquid biopsy in the routine management of your patients with metastatic NSCLC?
The dramatic improvement in the prognosis of metastatic NSCLC patients harboring targetable oncogenic genetic alterations with highly effective therapy has underscored the need for tumor molecular profiling. There have been numerous studies in the past decade assessing the performance of ctDNA (here...
Does recurrent or severe aspiration imply underlying oropharyngeal dysfunction despite a reassuring SLP/VFSS evaluation?
Attributing recurrent, clinically significant aspiration purely to the esophagus is mechanistically weak in the context of normal airway protective mechanisms. When the clinical picture is true macroaspiration, the coherent mechanisms are an oropharyngeal source with failed (often silent) airway pro...
How do you counsel patients on use of creatine monohydrate supplementation during a hospitalization for acute rhabdomyolysis from intense physical training?
I was a primary care doctor for the military for a few years. We regularly saw patients presenting with rhabdomyolysis from intense physical training. A standard question for all that present with this is whether supplements are being used. While there isn't a direct linkage to say that the use of c...